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DIVERSO PROFILO DI RISCHIO TROMBOEMBOLICO ED EMORRAGICO

Progetto Formativo ANMCO - AIAC UNIVERSO TROMBOSI ROMPERE IL LEGAME TRA FIBRILLAZIONE ATRIALE & ICTUS CONSIGLI D’AUTORE. DIVERSO PROFILO DI RISCHIO TROMBOEMBOLICO ED EMORRAGICO. 25 febbraio 2014 In collegamento con:

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DIVERSO PROFILO DI RISCHIO TROMBOEMBOLICO ED EMORRAGICO

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  1. Progetto Formativo ANMCO - AIAC UNIVERSO TROMBOSI ROMPERE IL LEGAME TRA FIBRILLAZIONE ATRIALE & ICTUS CONSIGLI D’AUTORE DIVERSO PROFILO DI RISCHIO TROMBOEMBOLICO ED EMORRAGICO 25 febbraio 2014 In collegamento con: Torino, Bergamo, Mestre, Bologna, Lucca, Roma, Napoli, Bari, Catania, Cagliari

  2. Italian Survey of Atrial Fibrillation ISAF Study 20.2% parossistica, 24.3% persistente, 55.5% permanente. Zoni-Berisso M. Am J Cardiol 2013;111:705-711

  3. AF significantly increases the risk of stroke • AF favours cardioembolism and is associated with a pro-thrombotic state1. Overall, AF imparts a ~5-fold increase in stroke risk2 • Up to 3 million people worldwide suffer strokes related to AF each year2-4 • AF-related strokes tend to be especially severe and disabling with a 1-year mortality rate of ~50%4,5 • Cardioembolic stroke has a 30-day mortality rate of 25%4 • Risk of stroke is the same in AF patients regardless of whether they have paroxysmal or sustained AF6,7 • Watson T, et al. Lancet 2009;373:155-166. • 2. Wolf PA, et al. Stroke 1991;22:983-988. 3. Atlas of Heart Disease and Stroke, World Health Organization, September 2004. 4. Lin HJ, et al. Stroke 1996;27:1760-1764. 5. Marini C, et al. Stroke 2005;36:1115-1119. 6. Rosamond W, et al. Circulation 2008;117:e25-146. • 7. Hart RG, et al. J Am CollCardiol 2000;35:183-187.

  4. The “3 Ps” and Natural History of Atrial Fibrillation Paroxysmal Self-Terminating Persistent Lasts > 7 Days Permanent Cardioversion Failed or Not Attempted Paroxysmal AF is as likely to cause stroke as persistent or permanent AF Normal Sinus Rhythm Atrial Fibrillation

  5. Mantainance of NSR and Risk of StrokeRate vs. Rhythm Control Trials Verheugt F, et al. J Am CollCardiol 2003;41(suppl):130A.

  6. AFFIRM TrialStroke Rates 74% of all strokes were proven ischemic • 44% occurred after stopping warfarin • 28% in patients taking warfarin with INR <2.0 • 28% in patients with INR>2.0 42% of all strokes occurred during documented AF Wyse AG, et al. N Engl J Med 2002; 347: 1825.

  7. ASSERT Study - Risk of Ischemic Stroke or Systemic Embolism is increased in Patients with asymptomatic atrial tachyarrhythmias HR 2.49; 95% CI, 1.28 to 4.85; P = 0.007 2580 patients with hypertension and no history of AF, in whom a PMK or ICD had been implanted. Patients were monitored for 3 months to detect subclinical atrial tachyarrhythmias (episodes of atrial rate >190 beats per minute for more than 6 minutes) and followed them for a mean of 2.5 years for the primary outcome of ischemic stroke or systemic embolism. N Engl J Med 2012;366:120-9

  8. Strokes with AF (N=216) Strokes without AF (N=845) AF-related strokes are associated with greater disability and a higher mortality rate Disability at clinical presentation1 30-day post-stroke mortality2 60 30 P<0.005 P<0.0005 P<0.048 50 25 40 20 Fatal strokes (%) Patients with clinical parameter (%) 30 15 20 10 10 0 0 Severe limb weakness Bedridden Strokeswith AF(N=103) Strokeswithout AF(N=398) Dulli DA, et al. Neuroepidemiology 2003;22:118-123. 2. Lin HJ, et al. Stroke 1996;27:1760-1764.

  9. Incidenza per 100 pazienti/anno di Stroke nella FA non valvolare: effettodeidiversifarmaci Nessuna terapia ASA ASA + Clopidogrel Warfarin Lancet 2006;367:1903-12 N Engl J Med 2009;360:2066-78

  10. Incidenza per 100 pazienti/anno di complicanzeemorragichemaggiori: effettodeidiversifarmaci ASA + Clopidogrel Warfarin ASA Lancet 2006;367:1903-12 N Engl J Med 2009;360:2066-78

  11. Stroke Risk in Atrial FibrillationUntreated Control Groups of Randomized Trials Stroke Rate (% per year) Age (years) Atrial Fibrillation Investigators. Arch Intern Med 1994;154:1449.

  12. Nonvalvular Atrial Fibrillation Stroke Rates Without Anticoagulation According to Isolated Risk Factors Stroke Rate (%/year) Heart Failure  LVEF Female Diabetes Prior Stroke/TIA Hypertension Age > 75 years Hart RG et al. Neurology 2007; 69: 546.

  13. High-Risk Factors Mitral stenosis Prosthetic heart valve History of stroke or TIA Less Validated Risk Factors • Age 65–75 years • Coronary artery disease • Female gender • Thyrotoxicosis Stroke Risk Stratification in AFClinical Stroke Risk Factors Moderate-Risk Factors • Age >75 years • Hypertension • Diabetes mellitus • Heart failure or ↓ LV function Singer DE, et al. Chest 2004;126:429S. Fang MC, et al. Circulation 2005; 112: 1687.

  14. Altri markers associati ad un incremento del rischio di Stroke in Pazienti con FA

  15. CHADS2 Score Defined and Validated to Predict Stroke in Atrial Fibrillation Patients Sum Gage BF, JAMA 2001;285(22):2864-2870 Gage BF, Circulation2004;110;2287-2292

  16. CV Event Rates in Patients with AF Related to CHADS2 Score REACH Registry Goto S, et al. Am Heart J 2008; 156: 855.

  17. The CHA2DS2-VASc Score Stroke Risk Score for Atrial Fibrillation Weight (points) Congestive heart failure or LVEF < 35% 1 Hypertension 1 Age > 75 years 2 Diabetes mellitus 1 Stroke/TIA/systemic embolism 2 VascularDisease (MI/PAD/Aortic plaque) 1 Age 65-74 years 1 Sex category (female) 1 Moderate-High risk > 2 Low risk 0-1 Lip GYH, Halperin JL. Am J Med 2010; 123: 484.

  18. The CHA2DS2-VASc Score Stroke Risk Score for Atrial Fibrillation Lip GYH, Halperin JL. Am J Med 2010; 123: 484.

  19. CHA2DS2-VASc versus CHADS2 Score • CHA2DS2-VASc Score has the advantage of identifying extremely low-risk patients with AF. • Among patients with a CHADS2 Score =1, approximately 70-75% have a CHA2DS2-VASc Score ≥2, while 25-30% have a CHA2DS2-VASc Score =1. • In patients with a CHA2DS2-VASc Score =1 the incidence of stroke is significantly lower. Eur Heart J. 2013 Jan;34(3):170-6

  20. Intracerebral Hemorrhage >10% of intracerebral hemorrhages (ICH) occur in patients on antithrombotic therapy Aspirin increases the risk by ~ 40% Warfarin (INR 2–3) doubles the risk to 0.3–0.6%/year ICH during anticoagulation is catastrophic The Most Feared Complication of Antithrombotic Therapy Hart RG, et al. Stroke 2005;36:1588

  21. First Month of Warfarin Therapy has High Bleeding Rate Fang MC. J Am Geriatr Soc 2006; 54: 1231-1236

  22. “Most intracranial hemorrhages (62%) occur at INRs < 3.0” Fang MC et al. Ann Intern Med. 2004;141:745-52

  23. Importance of the HAS-BLED Score Risk Score for Predicting Bleeding in Anticoagulated Patients with Atrial Fibrillation Weight (points) Hypertension (> 160 mm Hg systolic) 1 Abnormal renal or hepatic function 1-2 Stroke 1 Bleeding history or anemia 1 Labile INR (TTR < 60%) 1 Elderly (age > 75 years) 1 Drugs (antiplatelet, NSAID) or alcohol 1-2 High risk (> 4%/year) > 4 Moderate risk (2-4%/year) 2-3 Low risk (< 2%.year) 0-1 Pisters R, et al. Chest 2010; 138: 1093. Lip GYH, et al. J Am Coll Cardiol 2010; 57: 173.

  24. Redefining Risk vs Benefit for OAC HAS-BLED Lip GYH. Am J Med. 2011;124:111-114. ESC Guidelines: Eur Heart J . 2010;31:2369-2429.

  25. CHA2DS2VASc Score HAS-BLED Score Position Paper ANMCO sui NAO; G Ital Cardiol 2013;14(4):295-322

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